Borderline Personality Disorder (BPD)

Borderline personality disorder is characterized by unstable ways of seeing oneself, behaving, feeling, and relating to other people that interfere with one's ability to function.

Borderline personality disorder (BPD) is a mental illness that is part of the group of mental illnesses called personality disorders. Like other personality disorders, it is characterized by a consistent pattern of thinking, feeling, and interacting with others and with the world that tends to result in significant problems for the sufferer. Specifically, BPD is associated with a pattern of unstable ways of seeing oneself, feeling, behaving, and relating to other people that markedly interfere with the individual's ability to function. Also, as with other personality disorders, the person is usually an adolescent or adult before they can be assessed as meeting full symptom criteria for BPD.

Historically, BPD has been thought to be a set of symptoms that includes both mood problems (neuroses) and distortions of reality (psychosis) and therefore was thought to be on the borderline between mood problems and schizophrenia. However, it is now understood that while the symptoms of BPD may straddle those symptom complexes, this illness is more closely related to other personality disorders in terms of how it may develop and occur within families. BPD is now understood to occur equally in men and women in the general population, while mostly in women in groups of people who are receiving mental health treatment (clinical populations). The frequency with which this disorder occurs is also thought to be considerably higher than previously thought, affecting nearly 6% of adults throughout a lifetime.

Men with BPD are more likely to also have a substance-related disorder and women with this illness are more likely to suffer from an eating disorder. In adolescents, BPD tends to co-occur with more anxious and peculiar personality disorders like schizotypal and passive-aggressive personality disorder, respectively. Adults who have an antisocial personality disorder, also colloquially called sociopaths, may be more likely to also have BPD. Interestingly, even people who have some symptoms (traits) of BPD but do not meet full diagnostic criteria for the illness can have traits of both BPD and narcissistic personality disorder.

While there has been some controversy as to whether or not BPD is truly its disorder or a variation of bipolar disorder, research supports the theory that BPD, like virtually every medical or other mental health disorder, can present in nearly as many unique and complex ways as there are people who have it. In other words, some individuals with BPD will have that disorder alone, while others will have it in combination with bipolar or another mental disorder. Still, others will appear to have BPD but qualify for the diagnosis of bipolar disorder and vice versa.

Obsessive-compulsive disorder (OCD) can also co-occur with BPD. It is thought to be particularly true of people who have OCD and bipolar disorder. BPD is not recognized worldwide. It is most closely diagnosed as an emotionally unstable personality disorder in the International Classification of Disease, or ICD-10. Although countries like China and India recognize mental disorders that have some symptoms in common with BPD, its existence is not formally recognized.

Although there is no specific cause for BPD, it is understood to be the result of a combination of biological predispositions, ways of understanding the world, and social stressors (biopsychosocial model). Biologically, people with BPD are more likely to have abnormalities in the size of the hippocampus, in the size and functioning of the amygdala, and in the functioning of the frontal lobes, which are the areas of the brain that are understood to regulate emotions and integrate thoughts with emotions. Although some research indicates that people with BPD seem to have areas of the brain that are more and less active compared to individuals who do not have the disorder, other research contradicts that.

While BPD is not thought to be genetic, it can somewhat run in families. Psychologically, BPD seems to make a person more vulnerable to having unstable moods, particularly impulsive aggression. Socially, this disorder predisposes sufferers to develop insecurity, to be more likely to excessively expect to be criticized or rejected, and negatively personalize disinterest or inattention from other people. These tendencies result in BPD sufferers having significantly impaired social relationships. In addition to these problems, people with BPD are more likely to have suffered from trauma in the form of childhood abuse or neglectful parenting.

Adults who come from families of origin where divorce, neglect, sexual abuse, substance abuse, or death occurred are at higher risk of developing BPD. In children, the risk for developing this disorder appears to increase when they have a learning problem or certain temperaments. Adolescents who develop alcohol abuse or addiction are also apparently at higher risk of developing BPD compared to those who do not.

As per the DSM (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) definition, to qualify for the diagnosis of BPD, an individual must have at least five of the following symptoms:

• Distorted, unstable self-image, in that they may drastically and rapidly change in the way they understand their likes, dislikes, strengths, challenges, goals, and even their basic value as a person, even to the point of having feelings of worthlessness
• Repeatedly unstable relationships, in that individuals with this disorder repeatedly, rapidly, and drastically change from seeing another person as nearly perfect (idealizing) to seeing the same person as being bad or nearly worthless (devaluing)
• Unstable emotions (affects), in that the sufferer experiences marked, rapid mood swings (for example, severe depression/dysphoria, guilt, anger, irritability, joy, euphoria, anxiety, including panic attacks and sadness) that are stress-related, even if the stresses may be seen as minor or negligible to others
• Frantic efforts to avoid loneliness or being abandoned, whether the abandonment is real or imagined
• Significant impulsivity (the person tends to act before thinking), in at least two aspects that can be self-damaging (for example, sexual behaviors, eating or spending habits, driving behaviors, or in the use of substances)
• Repeated self-mutilating behaviors, thoughts of suicide, suicidal behaviors, threats, or attempts
• Chronic, persistent feelings of emptiness
• Inappropriate, intense hostility or anger, a lack of restraint, or other difficulty managing those or other potentially negative emotions when they occur
• Transient, stress-related paranoid thoughts or severe dissociation (lapses in memory)

There is no specific definitive test, like a blood test, that can accurately assess that a person has BPD. People who are concerned that they may suffer from BPD might further consider that possibility by taking a self-test, either an online or printable test. To determine the presence of this disorder, practitioners conduct a mental health interview that looks for the presence of the symptoms, also called diagnostic criteria, described previously. As with any mental health assessment, the health care practitioner will usually work toward ruling out other mental disorders, including mood problems, depression, anxiety disorders including anxiety attacks or generalized anxiety, eating disorders such as binge eating disorder, bulimia and anorexia, and other personality disorders including narcissistic personality disorder, dependent personality disorder or histrionic personality disorder, drug-abuse problems as well as problems being in touch with reality, like schizophrenia or delusional disorder. Besides determining if the person suffers from BPD, the mental health professional may assess that while some symptoms (traits) of the disorder are present, the person does not fully qualify for the condition.

The professional will also likely try to ensure that the person is not suffering from a medical problem that may cause emotional symptoms. The mental health practitioner will therefore often inquire about when the person has most recently had a physical examination, comprehensive blood testing, and any other tests that a medical professional deems necessary to ensure that the individual is not suffering from a medical condition instead of or in addition to emotional symptoms. Due to the use of a mental health interview in establishing the diagnosis and the fact that this illness can be quite resistant to treatment, it is of great importance that the practitioner conducts a thorough evaluation and interview family members, when appropriate with the patient's permission. This is to assure that the person is not incorrectly assessed as having BPD when he or she does not.

Clinical trials have determined that different forms of psychotherapy have been found to effectively treat BPD. Dialectical behavior therapy (DBT) is a method of psychotherapy in which the therapist specifically addresses four areas that tend to be particularly problematic for individuals with BPD: self-image, impulsive behaviors, mood instability, and problems in relating to others. To address those areas, treatment with DBT tries to build four major behavioral skill areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.

Another psychotherapy approach that is specifically designed to treat BPD is mentalization-based treatment. Based on an understanding of how, when, and the quality of attachments people form, its goal is to improve the person's ability to understand his or her own and others' mental states. This treatment approach uses weekly individual therapy and group sessions over 18 months.

Talk therapy that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy or CBT) has also been found to be an effective treatment for BPD. Schema therapy, also called schema-focused cognitive therapy, is based on a theory that many maladaptive ways of thinking (cognitions) are the result of past experiences. This approach to psychotherapy has also been found to alleviate the symptoms of BPD.

Other psychotherapy approaches that have been used to address BPD include interpersonal psychotherapy (IPT) and psychoanalytic therapy. IPT is a type of psychotherapy that addresses how the person's symptoms are related to the problems that person has in relating to others. Psychoanalytic therapy, which seeks to help the individual understand and better manage his or her ways of defending against negative emotions, is effective in addressing BPD, especially when the therapist is more active or vocal than in traditional psychoanalytic treatment and when this approach is used in the context of current rather than past relationships. Considered a form of psychodynamic psychotherapy, transference-focused psychotherapy involves the therapist clarifying, confronting, and interpreting the evolving reactions that the person with BPD has toward the therapist that are thought to be a repetition of the person's previous relationships (transference). Some BPD sufferers are found to benefit from this form of therapy, as well.

The use of psychiatric medications, like antidepressants (for example, fluoxetine, sertraline, paroxetine, citalopram, escitalopram, vortioxetine, venlafaxine, desvenlafaxine, duloxetine, vilazodone or trazodone), mood stabilizers (for example, divalproex sodium, carbamazepine, or lamotrigine), or antipsychotics (for example, olanzapine, risperidone, aripiprazole, paliperidone, iloperidone, asenapine), lurasidone, or brexpiprazole may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety. On a positive note, some women who suffer from both BPD and bipolar disorder may experience a decrease in how irritable and angry they feel, as well as a decrease in how often and severely they become aggressive when treated with a mood-stabilizer medication like Depakote. On the other hand, the use of medications in the treatment of individuals with BPD may sometimes cause more harm than good. For example, while people with BPD may experience suicidal behaviors no more often than other individuals with a severe mental illness, they often receive more medications and therefore suffer from more side effects. Also, given how frequently many sufferers of BPD experience suicidal feelings, great care is taken to avoid the medications that can be dangerous if taken in overdose.

Partial hospitalization is an intervention that involves the individual with mental illness is in a hospital-like treatment center during the day but returning home each evening. In addition to providing a safe environment, support, and frequent monitoring by mental health professionals, partial hospitalization programs allow for more frequent mental health interventions like professional assessments, psychotherapy, medication treatment, as well as the development of a treatment plan for after discharge from the facility. While funding a long-term stay in a partial hospitalization facility may be difficult, studies show that when it is provided using a psychoanalytic or psychodynamic approach, it may help the person with BPD enjoy a decrease in the severity of general discontent, anxiety, depression, and inability to feel pleasure, as well as decreasing the frequency of suicide attempts and full hospitalizations. This treatment may also help the individual develop improved relationships with others such that the BPD sufferer may be less likely to engage in social isolation. Contrary to earlier beliefs, BPD has been found to significantly improve in response to treatment with appropriate inpatient hospitalization. Family members of individuals with BPD might benefit from participation in a support group.

The presence of BPD often worsens the course of another mental condition with which it occurs. For example, it tends to change the symptoms of posttraumatic stress disorder and worsen depression.

Individuals with BPD are at risk for self-destructive behaviors like self-mutilation, as well as for attempting or completing suicide. While cutting and other forms of self-harm, as well as suicidal behaviors, seem to be associated with alleviating negative feelings, it is thought that self-mutilating behaviors are more an expression of anger, punishing oneself, distracting oneself, and maladaptively eliciting more normal feelings. In contrast, suicide attempts are thought to be more often associated with feeling survivors will be better off for their death. People who engage in self-mutilation are more likely to commit suicide compared to those who do not self-mutilate.

Although most individuals with a mental disorder do not engage in violent behavior, those who suffer from BPD have a somewhat increased risk for such behaviors. That risk is also increased for individuals who suffer from narcissism, antisocial personality disorder, have a history of previously engaging in violent behavior, frequent use of sedative medications, or experience several changes in their psychiatric medications in general.

Complications of BPD also often involve the families of the person with the disorder. For example, a parent with BPD is vulnerable to having depressive symptoms in their children.

Improvement in any personality disorder is not the same as being cured, in that while the symptoms of BPD do tend to diminish (remit) with time, some often remain. Therefore, full recovery can be difficult to achieve. But how well or poorly people with BPD progress over time seems to be influenced by how severe the disorder is at the time that treatment starts, the state of the individual's current personal relationships, whether or not the sufferer has a history of being abused as a child, as well as whether or not the person receives appropriate treatment and how long it takes for that to occur. Simultaneously suffering from depression, other emotional problems, or a low level of conscientiousness are associated with a greater likelihood of the symptoms of BPD returning (relapsing). Conversely, having steady employment or school status once symptoms of BPD subside (remit) tends to protect BPD sufferers from experiencing a future relapse.

People with BPD are at higher risk of having long-term substance abuse. Other complications that are associated with this personality disorder include unemployment, social isolation, reckless driving, legal problems, as well as suicide attempts, and completion.

Societal interventions like the prevention of child abuse, domestic violence, and substance abuse in families can help decrease the occurrence of several very different mental health problems. In contrast, specific prevention of BPD tends to focus on recognizing traits of the disorder as early as possible, followed by intensive treatment.

Borderline Personality Disorder Resource Center

National Alliance on Mental Illness (NAMI)

National Borderline Personality Disorder Resource and Referral Center
888-4-TARA-APD

National Education Alliance for BPD

National Institute of Mental Health (NIMH)

How can someone find a specialist who treats borderline personality disorder? 

DBT Therapists
http://behavioraltech.org/resources/crd.cfm